“At some point in our lives, we all have to cope with distress and pain…While we can’t always control the amount of pain in our lives, we can control the amount of suffering we have in response to…pain…” (McKay, et al, 2007)
Lately, my life has been quite stressful. I find my level of self-care and overall wellness falling into the crapper. For this reason, I’ve decided to see my old therapist once a month. I appreciate having somebody to “bounce things off of”. Currently, my educational goals are up in the air. I worry about finding a new internship placement. I worry about getting a job when it’s all over. Will all things fall into place? Against this backdrop of stress, I’m faced with many responsibilities, and an infuriating realization that so little is in my control…
“The first distress tolerance skills you’ll learn in this chapter will help you distract yourself from the situations that are causing you emotional pain (McKay p, et al, (2007).”
About three years ago, I was diagnosed with PTSD. In reality, I’ve had it quite a while as an undiagnosed disorder. The consequences of this are difficult to describe. The reality is, some hurts from our past leave their marks upon us. Like the death of a loved one – you can’t just forget it and move on. These things stay with you, and leave you forever changed….
….After a crapload of therapy and lots of hard work, I’m quite proud of where I’m at. The self-soothing skills below, were taught to me early in therapy and were a life-saver…
DBT Skills Groups are intended to provide clients a essential coping skills. What I liked were the acronyms that made the advice so easy to remember… Here “ACCEPTS” stands for the following list of distracting activities,
“A” = Activities
I have a bad habit of ruminating endlessly over things that worry me. When I catch myself doing this I distract my mind from what worries me. For example I will clean, exercise, blog 🙂 , or snuggle with my piglet.
“C” = Contributing
Contributing to the well-being of others is also a useful in coping with distress. Lately, this internship had provided a constant reminder that I have lots to learn and success isn’t guaranteed. For this reason, my job has actually been a respite from the stress. I am competent and everyone thinks highly of me. Contributing to the wellbeing of others as a healthcare worker takes focus off my own mundane concerns.
“C” = Comparisons
I get constant reminders at work of how lucky I am. I’ve enjoyed over 40 years of perfect health. At my internship are more reminders of my good fortune. I was raised in an upper-middle home. I make about 50k as a CNA. I’ve been happily married 17 years and have two amazing boys. I can’t complain really…
“E” = Emotions
Doing things that provide the experience of opposite emotions is essential. I like to listen to great music on my iPhone and exercise in the park. I love to draw and write. Netflix binge sessions on a day off are another favorite. Last but not least, hanging with my family doing just about anything brings me joy.
“P” = Pushing Away
When I notice myself ruminating over something that I can’t change/alter/remedy, I’m torturing myself needlessly. For example, worrying about finding a job when I graduate is useless. I can’t address the issue right now, so just shove those thoughts aside. Focus on right now, and worry about later – later 🙂
“T” = Thoughts
Thoughts that bring pleasure, hope, and excitement can eliminate or reduce distress significantly. Imagining myself as a successful therapist is much more useful. I will eventually land on my feet, and find myself where I’m meant to be.
Pleasurable sensations are also useful in alleviating distress and tension. I like the way I feel after exercise & hot whirlpool baths…
“The second group of distress tolerance skills you’ll learn….are self-soothing skills…necessary…before you face the cause of your distress. (McKay, et al, 2007)”
There are also distressing situations you’re thrown in that you can’t run away from. For example, I can’t run away from the therapy groups entirely. I must find ways to cope with the stress. What follows is another acronym of self-soothing skills….
“I” = Imagine
As a bullied child, I constantly found myself in inescapable situations that caused great distress and pain. My imagination was a salvation & respite from the distressing situation. I woud get lost in my own world, and mentally check out at school. I was there in body but not person, Today, I imagine relaxing situations at home & realize when the day is over, that’s where I’m going.
“M” = Meaning
Discovering the meaning & underlying purpose in today’s distressing events is also useful as a coping tool. My husband and I have talked at length about this. We work hard for our family, to provide them something better. Adding to this meaning, is the clear underlying purpose in my chosen line of work. I am a Kiersey Healer/INFP type. I derive greate meaning in my work as a caregiver /counselor. I enjoy opportunities to make an impact on people’s lives.
“P” = Prayer
I am agnostic, but still find great benefit in prayer. Having faith in something greater than yourself is comforting. Admittedly, I struggle to fully accept organized religion. However, a relationship with “my creator is essential…
“R” = Relaxation
When my husband is stressed, he responds by slowing down and relaxing at the end of a long day. In contrast, when I’m stressed, I go into high gear. I push through to overcome, hell or high water. This ego-driven adaptive response causes more problems than anything, I make mistakes when I rush through. Slowing down & relaxing can help my mind focus more on the task at hand.
“O” = One Thing
When I get stressed, I’m like a chicken with her head cut off. Stopping a minute to ask myself what needs to get done right now is critical. Focusing on one thing at a time – One-Mindfully is how I enter the moment fully present in it.
“V” = Vacation
Finding ways to take mini-breaks is useful. Last week a new intern started. Sensing my stress, she invited me to lunch. I enjoyed toe time we took to chat. It allowed me to regain some emotional equilibrium so I could focus on the task at hand.
“E” = Encourage yourself
I am unnecessarily hard on myself. My inner critic likes yelling at me whenever my performance is “less-than-stellar”. I need to be gentle and nurturing with myself. Encouragement needs to start within.
“DBT” is a therapy approach developed by Marsha Linehan. It is based on insights from Cognitive Behavioral Therapy as well as eastern meditative traditions such as Buddhism. The word “dialectical” refers to a concern with opposing ideas. Linehan’s DBT approach utilizes a combination of change and acceptance strategies. In this respect, a DBT approach upholds insight found within the serenity prayer:
God grant me the serenity
To accept the things I cannot change;
Courage to change the things I can;
And wisdom to know the difference.
DBT Basic Mindfulness Skills…
“Mindfulness is the ability to be aware of thoughts, emotions, physical sensations, and actions – in the present moment – without judging or criticizing – yourself or your experience” (Mckay, 2007, p. 75).”).
The concept of mindfulness is actually pretty simple (in theory): being fully present “in the here and now”. This sounds simplistic enough, but it requires two seemingly contradictory tasks. On one hand, mindfulness requires us to be fully present so we can fully experience our sensations and emotions. On the other hand, it requires this fully experience from a nonjudgmental perspective. In other words, mindfulness also requires us to examine our thoughts and feelings without becoming attached to them or identifying with them. In order to describe these two divergent perspectives, Marsha Linehan uses the terms emotional mind, logical mind, and wise mind:
The Logical Mind – Trusts facts and utilizes an empirically based thought process when making decisions. While critical in dealing with reality, the logical mind doesn’t handle emotions or interpersonal relationships very effectively.
The Emotional Mind – The emotional mind is ruled by passionate feeling states. The emotional mind is useful in handling matters of felt value as a reference point of understanding. For this reason, abstract values such as love are best understood from this viewpoint. However, the emotional mind is rather ineffective in handling pragmatic affairs of daily life.
“The Wise Mindis the ability to make healthy decisions about your life based on both your rational thoughts and your emotions…It is a decision-making process that balances the reasoning of your thoughts with the needs of your emotions” (McKay, et al, 2007, p. 75).
Observe without judgment.
Describe what is – “Just Notice”.
Fully participate in life.
I like to think of this as a “mental game”. Firstly, I set aside all judgments, emotions and beliefs. I let go of a need to cling to, run from, or push away facts. Instead I play a “devil’s advocate” position. I detach myself as if a disembodied teflon mind. Looking down at my life from this “safe distance”, what can I simply observe? While controlling my attention to what is happening, I witness inward the thoughts, sensations, and feelings that bubble up. Mind you, I’m not my feelings, instead I’m an observer of them.
Next I blog 🙂 🙂 . This involves putting words to the experiences and emotions. With vivid and rich detail, describe the goings on around you and within you. For those of you who are not “verbal processors”, I suggest getting an old camera and videotaping yourself. I did this when my kids were young and I didn’t have time to blog. I simply taped my thoughts and feelings in that moment. I would review it at a later time with my husband. The results were quite illuminating.
Becoming immersed with your experience requires you to forget yourself. Practice on losing your self-consciousness. Let go of the past, you can’t change it. Let go of your future, it hasn’t happened it. Admittedly, this is a tough one, but with practice you get better at it…
STEP TWO: How Skills
As I understand it, “how skills” describe this wise-mindfulness from a different perspective. How does it “look like” in action? How do you observe, describe, and participate?
Setting aside our beliefs, thoughts, and feelings for the time being, what are we observing. Looking around us what do the senses tell us about what’s happening. Looking within, what are you noticing about your reactions? What feelings and thought processes spring into your brain? How are you compelled to respond?
This is a tough one for me. First, letting go of future worries and past regrets, focus on right now. Next, since the brain is terrible at multitasking, focus on one thing. Do one thing at a time, prioritize, and let go of any need to “do it all at once”. Finally, resist any need to mentally or physically check out, (this is a tough one but its important). Stay here in the present, taking it all in.
I’m not good at this either. I was never known for my pragmatism. Step back, consider your goals. What is necessary to achieve them? What can you do in the present moment to bring yourself a step closer toward your goals?
As I stated earlier, this is easier said than done, but worth the effort.
Something interesting piqued my curiosity from all these blog post ideas. Clipped together were aa bunch of printed copies of various definitions and comments on “identity” as a construct. What is identity anyway? The first thought that comes to mind, would be my own verbal response to the answer “who are you?” Interestingly, the answer you get varies directly upon my mood at that time. To some extent, reflects the fact that I’m not so much a concrete constant, but ever-changing entity that exists in response to the needs of my environment. Anyway, here are a few random definitions in no particular order of importance…..
First a Definition…
IDENTITY: “experience of oneself as unique with clear boundaries between self and others; stability of self-esteem and accuracy of self appraisal; capacity for, and ability to regulate, a range of emotional experience.” (American Psychiatric Association, 2013, p823).
According to this definition, identity is an internal frame of reference in relation to the world us. This understanding of who we are is woven throughout our life experience as an understanding of those characteristics that are definitive of our nature.
Identity From the Inside…
The self is “nothing but a bundle or collection of perceptions which succeed each other with inconceivable rapidity and are in perpetual flux and movement.” (Jones, 1975, p305)
“The usual sense of the self as being who we ‘really are’ and as being continuous and consistent over time seems to be an illusory construction of imprecise awareness. Closer examination reveals that the self-sense is continuously and selectively constructed from a flux of thoughts, images and emotions. This is similar to the ‘flicker fusion phenomenon’ by which photographs projected successively on a move screen give the illusion of continuity, vitality and movement….this bears a crucial contemplative claim: that we suffer from a case of mistaken identity. We are not who, or even what, we thought we were. What we take to be our real self is merely an illusory construct” (Wedding & Corsini, 2013, p467).
These quotes force one to consider the imprecise nature of identity. It doesn’t always reflect facts as much as it does ego-driven emotions, beliefs, insecurities. As it states above “who we take to be our real self is merely an illusory construct” (Wedding & Corsini, 2013). So when is it okay for others to question our asserted identity? How does one discern between truth and bullshit? — Or is this a politically incorrect question to ask??
Identity From the Outside…
“Psychology has nothing to do with the other person’s experience, but with his behavior. I see you, and you see me. I experience you and you experience me. I see your behavior. You see my behavior. But I do not and never have and never will see your experience of me. Just as you cannot “see” my experience of you. My experience of you is not “inside” me. It is simply you as I experience you. ….Your experience of me is not inside you and my experience of you is not inside me, but your experience of me is invisible to me and my experience of you is invisible to you. I cannot experience your experience. You cannot experience my experience. We are both invisible men. All men are invisible to one another. Experience is man’s invisibility to man. Experience used to be called the soul.” (Laing, 1990, p18).
This comment on identity focuses on the fact that others’ are “guessing at” what lies within. In this respect, while we can often be mistaken about “what we are”, others are comparatively clueless to the power of ten. They see behavior, and make assumptions on it. In light of this fact, why do we allow others to tell us who we are, if they don’t know what the hell they’re talking about.
And Yet, an External Frame of Reference is Essential….
“what is important is knowledge of the meaning of these identities. Depending on one’s reference point, there may be more than one meaning for the same identity. That is, a particular identity may have one meaning in the dominant culture, another in a minority culture, and still another person-specific meaning for the individual” (Hays, 2008, p76).
“The sense of identity, requires the existence of another by whom one is known; a conjunction of this other person’s recognition of one’s self with self-recognition.” (Laing, 1960, p149).”
While our knowledge of self is imprecise at best, others are often left to “guess at” our internal workings. Where does the grain of truth, lie? The quotes above, describe others as an essential frame of reference in the construction of our identity. Cultures provide systems of meaning as a reference point. Interactions provide a sense of self-recognition.
So what Purpose does Identity Then?
“A firm sense of one’s own autonomous identity is required in order that one may be related as one human being to another. Otherwise, any and every relationship threatens the individual with loss of identity….instead of the polarities of separateness and relatedness based on individual autonomy, there is the antithesis between complete loss of being by absorption into the other person (engulfment), and complete aloneness (isolation).” (Laing, 1960, p46).
We are social creatures at heart and grow in relation to those around us. A delicate balance is required somewhere between isolation and engulfment. Identity appears to lie as a byproduct of our interaction with the outside world. Would it be more accurate to characterize identity as a verb than a noun???
What are Our Solutions???
“Whereas Western therapies teach us that we can modify our self-image, contemplative therapies teach us that we can also do something far more transformative and profound: We can recognize that our self-image is only a fabrication, and can thereby dis-identify from it and become free of it.” (Wedding and Corsini, 2013, p467).
I’m not sure if this blog post was useful at all in answering any of my questions. The more information I find, the more questions I have. With this in mind, I’m stopping here. The above quote can allow me to “finish off” this post on a positive note. Self-responsibility is the key to empowerment. By understanding where bullshit lies, we can see beyond our socially fabricated selves.
Last week, the professor for my internship class began our weekly meeting with the following statement: “nothing tastes better than a stolen watermelon.”
Noting the perplexed looks on our faces, he offered an explanation. We were treated to a short story about a boy who steals a watermelon, noticing the ones he steals are much “sweeter”. The obvious moral to his story: perception often influences our experiences than the event itself. The question he then asked is: why does stolen watermelon taste better?? The unexpected delight of enjoying ill-gotten booty, is what increased the boys pleasure of the watermelon….
….this story naturally resulted in a class discussion on recent observations we had clients that week. I left that day reflecting on how my own life had at times, been affected by poorly thought-out hedonistic desires…
In my worn out mental state, it took me some time to figure out where I heard this story before:
When considering the issue of hedonistic logic (if there is such a thing), what sort of behavioral freakonomic principles guide our decisions?
As I pondered this question, one individual came to mind: Social Psychologist, Daniel Gilbert. I first learned about his work when I watched the PBS Documentary series: “This Emotional Life”. Naturally, as a self-help junkie I bought his book “Stumbling on Happiness”. Finally, in the context of my educational endeavors, I’ve read some of his research articles. What follows are intriguing insights based on his work, as they apply to my own lived experience:
Hedonistic Behavioral Freakonomics 101
#1. PERCEPTION OF EVENTS –
“The representation of…an object is…empowered to guide behavior as if it were true prior to a rational analysis of the representation’s accuracy. (Gilbert, 1991, p. 116).”
The importance of belief in comprehending assorted life events….
In an article titled: “How Mental Systems Believe”, Gilbert, (1991), provides insight on how we make sense of our lives. Research seems to shows that problems aren’t often a matter of “what we’re looking at but how we are choosing to look at it”. Gilbert, (1991) explains that acceptance of an idea is critical to a comprehension of it. If you think about it, assessing a life situation requires us to examine what it “means to me”. What are the knowable facts in this situation? What does this mean for my future goals and plans? How do I feel about the direction is heading in?
For example, I have been forced recently to make a tough decision about my education. I’m dropping out next quarter in order to find an internship placement that can better fit my specific needs. My mind is filled with anxieties about what the future holds.
*What if I don’t find anything better?
*How long is it going to take me to graduate
*Will I be able to find a job once I’m done?
Depression sets in as I consider the treacherous path to here. I’ve really paid a huge price for those early childhood traumas. I mourn a loss of something abstract missing within. My mind fills with anger over the unhealable hurts left behind….
….As I type these very words, the emotions melt away like an ice cube on hot pavement. Slowly emotional equilibrium is restored, and with it a sense of clarity, I can’t help, but laugh at what I’ve just typed….
So how might Gilbert’s insights apply to this situation????
In a recent post titled “Nature of Belief Systems”, I define belief as either: (1) an expression of trust and faith in something or (2) the acceptance that something is true and exists. Defined in this way, beliefs represent a “what if” mental representation of our situation. In order to understand the long-term implications of my decision, I must first accurately comprehend the facts: (1) I need my job, (2) I can’t reduce my internship hours, (3) I can’t maintain this 70 hour schedule for the next year….
So with this as my current reality, how might I analyze my options, and the consequences of my decision? My approach has been to examine all potential alternatives from a “what if” perspective. What might the outcome of each option be? How will I feel about this “what if”? In this sense an accurate understanding of things requires both comprehension and acceptance. This acceptance allows me to wrestle with the question: “what does this situation mean for me?” In this respect belief is a component of part of our personal meaning making process.
*Beliefs are often misinterpreted as byproducts of external events…
*Beliefs also exist as a cause for the events themselves. Situations can be believed into being.
According to Gilbert, (1991), doubt is much more difficult…
Gilbert, (1991), uses the term “cogntive business” to describe the mental state of somebody who is attempting to multi-task. As a wife, mother, full-time student, & healthcare worker, I constantly have several “irons in the fire”. Typically, individuals examine hypothetical alternatives by examining them “as if” they are true. By comparing these alternative mental representations of a life event, we can better understand how we feel about the options. It is only through this process that inconsistencies are then uncovered. Doubt, develops later as truth dissipates and fallacies emerge. The entire process is 10x more difficulty if you’re “cognitively busy”.
“the ontogeny of belief is at least consistent with the idea that unacceptable is a more difficult operation that acceptance. Not only does doubt seem to be the last operation to emerge, it also seems to be the first to dissappear, Gilbert, 1991, p111).”
#2. UNDERSTANDING OUR CHOICES –
The next intriguing insight in Gilbert’s work, pertains to how we make sense of the options available to us. How do we determine what we feel about the options available? Wilson, Gilbert, et al, (2003), use the term affective forecasting is used for “people’s predictions about future feelings (p. 346).” The meaning of current events and the actions we take are based on how we believe we might feel in the future,…
I imagine graduation as a wondrous day. The ten-ton weight of this long journey, I can now move forward. I get weekends free. No more papers or exams, (yippie!!)
I imagine graduation as a terrifying culmination of years of effort. Will it prove fruitless in the end? Will I find a job waiting for me at the conclusion of this journey?
Affective forecasting requires us to develop an understanding of our situation. Once we have a mental representation of events that satisfies us, we can begin predicting future feelings.
Wilson, Gilbert, et al, (2003) describe four components of affective forecasting….
*We try to predict the specific nature of our future feelings…
*We try to predict the valance (+/-) of our emotions.
*We try the intensity and duration of what we will feel…
As you might suspect, we tend to make mistakes at every step in the process and are often quite lousy at knowing what we will feel at some future point. Mistakes can be right at the outset, when we misconstrue a situation, and develop faulty representation of it. Wilson, Gilbert, et al, (2003), also note errors in prediction within each of the four components of affective forecasting. While we are often accurate in predicting the general nature of our emotions, we are often inaccurate in knowing the degree of those emotions. Additionally, our future predicted emotions are often imagined in an “overly simplistic” (Wilson, Gilbert, et al, 2003, p348) manner. Finally, we tend to overlook our abilities to acclimatize emotionally to situations. Over time, as the “newness” of a situation wears off, we tend to revert to an emotional homeostasis. Gilbert, et al, (2000), describe this unique ability as our “psychological immune system”….((more on that later))
#3. SENSE-MAKING & EMOTIONAL EQUILIBRIUM…
“people’s emotional reactions to life events become less intense with time, a phenomenon we call emotional evanescence” (Wilson, Gilbert, et al, 2003).
Over the years, I’ve been fascinated at how the healing process is affected by things beyond our control or understanding. At work are spiritual and psychological factors that allow individuals to heal, recover, and thrive great physical and emotional trauma. When encountering patients like this the psychological immune system is vividly displayed before me. From time to time, I find myself imagining what it is like to be in their shoes: (quadriplegia, cancer, et). The idea of this in a “what if” sense produces unthinkable negative emotions.
According to Gilbert’s research the sense-making processes underlying our ability to re-establish an equilibrium involve four key phases…
“First, people orient to unexpected but relevant information in their environment.” (Wilson, Gilbert, et al, 2003, p. 371)
As it pertains to my current educational endeavors, I’m currently in the emotional rollercoaster phase. Internship requirements entail an array of unexpected factors that often act as monkey wrenches in our well-laid plans. Preconceived notions of the counseling profession are immediately challenged by the daily realities of the job. New areas of interest open up that you hadn’t considered previously. The daily grind of family life, work, and internship responsibilities can quickly overwhelm one. This produces heightened stress and exhaustion as your self-care falls into the toilet. In my current set of circumstances with every unexpected bit of information my mental state falls into An unpredictable flux.
*Learning of recent changes in program requirements leaves me worried about how this influences my projected graduation date.
*Hearing about opportunities to work kids, leaves me feeling hopeful.
*Realizing that an unexpected illness has result in a doubling of my group therapy class workload, I’m now stressed.
“Second, people have more intense emotional reactions to unexpected, relevant information than to other events.” (Wilson, Gilbert, et al, 2003, p. 371)
With each bit of new information, I’m hit out of left field. Since it comes at me in the midst of a busy day, my mind is preoccupied and I’m thrown into a mental flustercuck. Left with an uncertain future, it often seems in that moment as if the “rug has just been pulled out from under me”. Without an ability to stop and consider this new information thoughtfully, my own worry-wart nature takes over. I vacillate between anxiety, stress, depression, and periods of hopelessness. You see, this endeavor has been the result of just under six years of effort. Its been a long journey, and I would really hate to come out of this “empty banded” with nothing to show for myself.
“Third, once an unexpected event occurs and people have a relatively intense emotional reaction, they attempt to make sense of the event, quickly and automatically.” (Wilson, Gilbert, et al, 2003, p. 372)
As soon as it becomes clear that these crazy hours (70+) are more than I can handle, I decide to switch gears. After struggling to find a new internship placement at the last minute, I’m forced to accept that I might need to “take a quarter off”. I vacillate between depression, stress and excitement at the idea of having time off. These last two weeks have been a crazy rollercoaster and I need to find a way to regain equilibrium. How does one learn to have faith in the end goal, despite a continual onslaught of facts that each lead one to a different conception of what the future might hold?
“Fourth, when people make sense of an event it no longer seems surprising or unexpected, and as a result they think about it less and it produces a less intense emotional reaction.” (Wilson, Gilbert, et al, 2003, p. 373).
I talked with my mom earlier today. She shared me the story of her long and arduous educational journey. As a retired physician, she has loads of advice. I told her I’m going to take a quarter off while seeking a new internship opportunity. I’m taking advantage of this time off to focus on passing the licensure exam. In the course of her career, she has had to take an exam for licensure 3x in her life. She described doing this once while working full-time and holding down the fort at home alone while our dad took a 6-month research sabbatical opportunity in California. Her mental state was very much like mine. She was overwhelmed and drained….
It helped to hear this story. Today while “clocking some hours” at my internship site, I heard similar stories. Since many of them are nontraditional students, they had survived what I’m going through now. I didn’t feel so alone, and am coming to acclimatize to the experience.
Errors in Cost-Benefit of Life Events & Goals…
The information above provides a quick-and-dirty overview of the process of affective forecasting: (how we predict “future feelings” as a result of present-day decisions). In this section, I’d like to review common sources of error in predicting “future feelings”. Affective forecasting errors cause miswanting. “Miswanting is the case in which people do not like or dislike an event as much as they thought they would (Wilson, et al, 2000, p. 821). These cost-benefit miscalculations cause a great deal of rainbow chasing. We create complex plans and lofty goals to achieve an idealized future state of preconceived happiness. Meanwhile, opportunities for happiness in the present are readily available around us, should we choose to pay attention…
“We treat our future selves as thought they were our children, spending most of our days constructing tomorrows that we hope will make them happy. rather than indulging in whatever strikes our momentary fancy, we take responsibility for the welfare of our future selves (Gilbert, 2009).”
With all this said, here are common miscalculations that pertain to most of us…
Misconstruing a situation is a result of an inaccurate mental representation of events. This miscalculation can cause a huge miscalculation in our prediction of “future feelings” due to a complete misrepresentation of the event itself.
“Empathy gaps and projection bias suggests that people who are in one psychological state…have considerable difficulty predicting how they will think, feel, and act when they are in the opposite psychological state.” (Gilbert, et al, 2002, p. 430). Projection bias involves assuming current preferences pertain to our future selves. Empathy gaps happen when we are unwilling to see beyond our current transitory feeling state.
“People often fail to anticipate the extent to which unrelated events will influence their thoughts and emotions….by neglecting to consider how much these other events will capture their attention. Wilson & Gilbert, 2003, p366).”
“[People] may predict their feelings by forecasting (imagining their feelings when the impacting event occurs…or by backcasting (imagining their feelings in a future period, then considering how these feelings would be different if something happened. (Ebert, et al, 2009, p. 353). Interestingly, research shows that forecasting & backcasting greatly influence how we predict the hedonic impact of future events.
“People seek extraordinary experiences – from drinking rare wines and taking exotic vactions to jumping from airplanes and shaking hands with celebrities. But are such experiences worth having?…Studies suggest that people may pay a surprising price for the experiences they covet the most (Cooney, Gilbert, & Wilson, 2014, p.2259).”
“Although negative expectations may have the benefit of softening the blow when a negative event occurs, they also have the cost of making people feel worse while waiting for that event to happen” (Golub, Gilbert, & Wilson, 2009, p. 277). In other words, being a worry wart doesn’t really do anybody any good.
Daniel Gilbert (2000) utilizes the term Immune Neglect to refer to the fact that “people generally underestimate their capacity to generate satisfaction with future outcomes” (p. 690). We often attribute it to external agents and overlook our tendency to “subjectively optimize suboptimal outcomes (Gilbert, et al, 2000, p. 691). This psychological immune system is quite powerful and allows us to maintain a homeostatic emotional balance throughout life.
Cooney, G., Gilbert, D. T., & Wilson, T. D. (2014). The unforeseen costs of extraordinary experience. Psychological science, 25(12), 2259-2265.
Ebert, Jane E. J., Daniel T. Gilbert, and Timothy D. Wilson. 2009. Forecasting and backcasting: Predicting the impact of events on the future. Journal of Consumer Research 36(3): 353-366.
Gilbert, D. T., Brown, R. P., Pinel, E. C., & Wilson, T. D. (2000). The illusion of external agency. Journal of personality and social psychology, 79(5), 690.
Gilbert, D. T., Gill, M. J., & Wilson, T. D. (2002). The future is now: Temporal correction in affective forecasting. Organizational Behavior and Human Decision Processes, 88(1), 430-444.
Gilbert, D. T., Pelham, B. W., & Krull, D. S. (1988). On cognitive busyness: When person perceivers meet persons perceived. Journal of personality and social psychology, 54(5), 733.
Gilbert, D. (2009). Stumbling on happiness. Vintage Canada.
Golub, S. A., Gilbert, D. T., & Wilson, T. D. (2009). Anticipating one’s troubles: the costs and benefits of negative expectations. Emotion, 9(2), 277.
Wilson, T. D., Wheatley, T., Meyers, J. M., Gilbert, D. T., & Axsom, D. (2000). Focalism: a source of durability bias in affective forecasting. Journal of personality and social psychology, 78(5), 821.
Wilson, T. D., & Gilbert, D. T. (2003). Affective forecasting. Advances in experimental social psychology, 35, 345-411.
I honestly can’t tell you how many times I’ve attempted to start a blog, only to stop just shy of “going live”. It wasn’t until I actually decided to go back to school, that I finally gave up on the idea. I reasoned with “so much on my plate”, there just wouldn’t be any time. I shoved all my ideas and well-laid plans into a few storage bins. They remained there until late last 2015……
My goal for this blog, has simply been to finish what I start and cross something off my bucket list. I’m proud to say, I finally succeeded in producing forward motion in the direction of this goal.
I’m actually making slow and steady progress in the direction of my goal. I regularly dig through these old storage bins in the back of my hallway closet for another source of “inspiration”. While I’m grateful to not be stuck anymore, its taken me some time to understand exactly what was stopping me to begin with….
My therapist has nesting dolls in her office, and utilizes them to illustrate various ego states from transactional analysis. When initially considering this issue of stuckness, my therapist’s nesting dolls came to mind. Resistance from this theoretical perspective can be “explained as a battle between inner parts: one part wants to change, while the other does not…” (Ingram, 2013, p 234). According to transactional analysis, within us exist ego states that represent experiential realities from various stages in life. Within each ego state is a typical coping style or pattern of relating to those around us. As I recall, two in particular have been engaged in a perpetual lifelong battle….
My Hurt Child
The child ego state can be thought of as an inner mental recording of painful childhood experiences. When encountering triggers that remind us of these events, we’re sent back in time. Emotionally, we can re-enact these early experiences with those around us. For example, within me lives a “hurt child” who was bullied kid and had no friends. This hurt child asks, “I know I am bad; what’s wrong with me” (Ingram, 2013, p. 295). She is submissive, insecure, with no sense of self. Filled with a sense of shame, she seeks validation and acceptance from others – wherever she can get it…
My Critical Parent
The parent ego state reflects messages we receive from authority figures in our lives and standards of conduct we were taught. My own critical parent, consists of messages from my parents that emotions were bad and creativity was a waste of time. My critical parent consists of message from parents and teachers who ignored and overlooked the bullying.
My critical parent might say “you should take those pounds off. What’s wrong with you?! Your an indulgent loser (Ingram, 2013, p. 295).”
My hurt child will be filled with feelings of insecurity as a former “ugly duckling”. Shame takes over in reaction to the random characteristics that happen to define my meatsuit
The insights from transactional analysis described above, are useful in developing a historical context for my history of life-long stuck-ness. Underlying this perpetual resistance was unresolved trauma, that I would later come to understand as PTSD. Still, I have more questions:
In particular, how can I be certain I won’t get re-stuck? After all, the PTSD isn’t going away, and the triggers are still there….
Today, after “clocking some hours” at my internship site, I decided to dig in those old storage bins, and do more blogging. As an INFP, I find it is a relaxing activity at the end of a long day. Serendipitiously, I happened to come across Malcom Gladwell’s titled “The Art of Failure”. In it describes the differences between choking & panic:
“If panicking is conventional failure, choking is paradoxical failure. (Gladwell, 2000)”
In order to explain what is meant by this statement, it is important to first understand the difference between explicit and implicit learning:
EXPLICIT LEARNING: commonly utilized with novices and involves the conscious utilization of intentional focus & deliberate action. For example, I don’t play golf, and if somebody teach me, I’m paying attention to the particulars of how to hold the club.
IMPLICIT LEARNING: common with experts and occurs at a subconscious level, outside one’s awareness. An unexplainable knowing guides our process, and we’re kind of “in the zone”. I do this when I play the violin. I’m not paying attention to the music, I’m not really aware of how I hold the violin or bow. My fingers somehow know what to do. My attention is instead on the music and playing what I hear and feel within me.
Choking: Thinking To Hard
Choking is a paradoxical failure that comes when we are expected to perform and our brain freezes. This happened to me whenever I had a violin recital. My teacher liked to schedule them at the local churches on Sunday. Since we lived in a small town, it was inevitable that a classmate, (or two), were present. As a bullied child, I was pretty much a social leper. Fear rushed through me, and I my mind completely froze as a panic overcame me. I tried so hard to do my best, I paid attention to my fingering, and tried focusing on the sheet music before me. It never worked, I was “overthinking things”….
Panic: Not Thinking at All
With panic the fight-or-flight system takes over and we begin acting on adrenaline and instinct. Whereas choking is about loss of instinct, panic is a reversion to instinct. When we panic, we focus only on our end goal, and can’t generally see beyond our fear. It is conventional in the sense that it is a byproduct of knowing being thoroughly educated in how to handle a situation. For example, my son went into cardiogenic shock as a child, d/t an undiagnosed heart defect. I panicked yet somehow managed to make it to the hospital – by the grace of God….
SECONDLY, How can I know it won’t happen again?
I’m finally reaching the end of my educational journey, and look forward to launching a new career. The road hasn’t been without its hitches. I wonder, from time to time, if I’m hitting stuck-ness again. Recently, I started my first internship class, and found myself teaching five group therapy classes independently. The first few weeks were quite rough and riddled. However, I’m relaxing into the role. I have to admit honestly, there isn’t anything I can look to for a guarantee I won’t get re-stuck. Only a personal commitment can do that:
An Underdog’s Credo…
I am an underdog.
An underdog is an unlikely hero who rises from “modest beginnings” despite mounting challenges. Overcoming “less than” conditions with few expectations of success at the outset I have stuck with it like a turtle. Slowly but surely I’ve moved towards my goals.
I stick my neck out.
As that little engine that could, I overcome self-imposed limitations, and messages from everyone who doubted me. I choose today to meet insecurity head on with passion and determination. This happens everytime I chose to not let past mistakes define me. I have faith in my abilities and the motivations driving me forward.
I have everything I need to get there.
Like Dorothy and her ruby slippers, I have everything I need to make things happen, I just need to believe in myself. I now realize the key to empowerment is self-responsibility as I decide to critically examine my own self-imposed idiocy. I become what I believe I am, and get what I believe possible.
I commit to owning my truth.
There’s more than a grain of truth to the saying that we perpetuate what we deny. Owning my truth means understanding how I exist as a creator of my life. If I do become what I believe I am, what do I believe I am? If I become what I believe is possible, what is possible? Where did these messages come from???
I understand that stuckness is a matter of my own doing & opportunity for personal growth.
I’m not running from somewhere or going to anywhere. I’m at peace with where I’m at. Stuckness for me has been a byproduct of a failure to understand the motivational forces goading me forward. When based on insecurity and a desire to prove myself worthy, I end up creating more to be insecure about. Today, I’m in a different place. I’m content with where I’m at. I’m good enough as is. My life is splendid and I have a lot to be grateful for. I flow in the direction life takes, and face every day fully present, and see it as an opportunity for personal growth.
I choose opposite action away from old habits & towards my personal goals.
The good thing about making mistakes, is you have them as a template for what doesn’t work. I’ve gone down that road, where old habits, and personal insecurities have taken me. The benefit of 20/20 hindsight is the clarity that comes with m extricating my head from my rear.
I do not fear failure, it is an opportunity to grow.
Insecurity is no longer a ruling force in my life. I don’t fear failure since it no longer equates with the idea that I’m a “loser”. I also don’t equate success with the idea of being a “winner”. My value is independent of any success vs. failure tally. Failure present an opportunity to learn. Success presents an opportunity to reflect upon the journey to “here”.
I’m not worried about the goal itself, I focus instead on the journey.
My mother has a saying she likes to repeat often that “its not the journey but the destination that matters”. I love this statement, and live by it. Focusing on end goals, takes us away from the present. In the end, the present is all we have. There is too much in this moment I have to be grateful for, I hate the idea that anything might take me away from it…
As an “INFP”, I’ve always been fascinated by the varied styles of affective communication that existed in my family….
While flipping through some old journals for another blog post idea, I came across the commentary above on attitudes towards emotions. Understanding attitudinal differences towards feeling is critical in our attempts at communication of empathy. Professionally, as a student therapist, my motives for understanding this issue should be obvious. Personally, understanding attitudinal differences towards emotion has been critical in the healing of my relationship with my mother.
I will begin this post, by including relevant excerpts from a paper I wrote some time ago titled “Culturally Inclusive Empathy.”
Against this backdrop of understanding, I hope to process some insights I’ve been mulling over after along week as wife, mother, blogger, student therapist, and caretaker…
#1. PAPER EXCERPTS: Culturally Inclusive Empathy….
Empathy is derived from the German word “Einfuhlung” which directly translated means “one feeling”, (Pedersen, et al, 2008, p42). From this perspective, empathy can be thought of as an ability to understand another’s experiences as if they are your own. Best understood as an ability to relate to others due to shared experiences, the western Euro-American definitions predominating mental health are clearly problematic (Pedersen, et al, 2008). With traditional conceptions of empathy tending to reflect this cultural viewpoint, a more culturally inclusive perspective is vital. (Chung, 2002; Pedersen, et al, 2008). What follows is a definition of this concept from literature:
“Inclusive Cultural Empathy describes a dynamic perspective that balances both similarities and differences at the same time integrating skills developed to nurture a deep comprehensive understanding of the counseling relationship in its cultural context.” (Pedersen, et al, 2008, p.41)
“Emotions can be defined as psychological states that comprise thoughts and feelings, physiological changes, expressive behaviors, and inclinations to act.” (Vohs, et al, 2007, p285). Overall, two divergent perspectives exist regarding research that focuses on the nature of emotion. Appraisal theories are based on the premise that emotions result from the way we appraise and interpret our environment…Categorical theories tend to view emotions as universal, innate and discrete.
Categorial Theories of Emotion.
Some research exists which focuses on a limited number of universal emotions, described as “basic” in nature. and byproducts of neural programming hardwired into the species overall. Research reflecting this perspective utilizes a “Universality Thesis of Emotions.” (Effenbein & Ambady, 2002). While still asserting some degree of cultural variation, this perspective stresses the universality to facial expressions across culture. (Ellsworth, 1994; Ekman & Friesen, 1971). The Universality Thesis of Emotion proposes that facial expressions and attribution of emotion can be observed as universal across cultures,(Russell, 1994).
Emotion: A Cultural Perspective.
Appraisal theories of emotions interpret emotions as byproducts of the way people interpret and understand their environment, (Ellsworth, 1994). Research utilizing this theoretical perspective has traditionally focused on a few key dimensions such as: (1) individualism/collectivism, (2) certainty/uncertainty (3) Attention to Novelty (4) Valence/Degree of Perceived Pleasantness, (Ellsworth, 1994). Differences in emotional expression are largely attributed to emotional regulation, stating that culture defines the beliefs about appropriateness of emotional expression. Accounting for differences in understanding of emotional expression, the assertion is made that culture “provides a framework for understanding culturally general emotional phenomena,” (Ellsworth, 1994)
For example emotions can be observed as a component of social interaction. From this perspective they aren’t internal affective states influenced by cognition but a form of interaction. (Frijda & Mesquita, 1994). We “transmit important messages about ourselves in relation to our surroundings” (Leu, 2001), and behavior from within the framework of culturally meaning systems. Emotion in this respect contains five characteristics reflective of culture including: “1. quality, 2. intensity, 3. behavioural expression, 4. the manner in which they are managed and 5. Organization.”(Leu, 2001).
“A cultural framework includes a group’s sense of and attitudes toward emotions, that is what emotions are or feelings are, why they are experiencing, and what their significance is in social life, as well as the implicit answers to questions like when does one feel, where does one feel, and how does one feel.” (Frijda & Mesquita, 1994, p.99)
When viewed within the context of a perceptual process, culture’s influence over emotions can also be observed. For example, individuals experience emotions in response to events they encounter that are deemed significant. Our appraisal of situations reflect culturally relevant systems of meaning.
Inclusive Cultural Empathy.
Defined as an ability to put yourself in someone else’s shoes, empathy is a culturally relevant concept. Traditional perspectives of empathy are self-limiting, based on a perspective that is empirical and individualistic in orientation. In contrast, culturally inclusive empathy is a useful dynamic perspective that requires two seemingly divergent viewpoints. Essentially, this concept requires a counselor to hold onto their own cultural perspective while appreciating their client’s as well. can best be understood as a dynamic process that exists as an exchange between client and counselor, (Pedersen, et al, 2008). It comprises three key skills: Affective Acceptance, Intellectual Understanding, & Appropriate Interaction (Pedersen, et al, 2008). With intellectual understanding best understood as a knowledge of similarities and differences, it is an essential to note this is not enough in and of itself. Affective acceptance requires that a counselor acknowledge culturally learned assumptions underlying divergent forms of affective communication (Pedersen, et al, 2008). Finally, effectively communicating this means developing key interactive skills and abilities through ongoing direct contact within the community (Pedersen, et al, 2008)
“Counselors will not be effective working with clients from different cultural backgrounds if they cannot communicate cultural empathy in a way that demonstrates that they understand and appreciate the cultural differences and their impact on the therapeutic process. Ridley (1995) identified the following seven guidelines….(a) describe in words to the client his/her understanding of the client’s self-experience; (b) communicate an interest in learning more…; (c) express lack of awareness…; (d) affirm the client’s cultural experience; (e) clarify…communication; (f) communicate a desire to help the client work through personal struggles; and, (g)… help the client learn more about himself or herself …” (Chung & Bemak, 2002, p157)
#2. OBSERVATIONS: (Journal Excerpts & personal observations).
The above paper is a “cliff notes” version of research I’ve done on the subject of emotions. Fueled by a desire for personal understanding and professional growth, this endeavor has been more than simply an attempt to complete assignments. What follows are insights from direct observations with clients…..
Primary & Secondary Emotions
A fellow intern I work with is conducting an anger management class. Since this facility is currently “reworking their curriculum”, we’re scrambling week-by-week to design it ourselves. As we worked to determine the subject for this weeks classes, I noticed she began printing off material on primary vs. secondary emotions. Hearing these terms brought back memories of a DBT skills group I had participated in “many years ago”. According to Marsha Linehan, while primary emotions comprise our immediate reactions to an event, our secondary emotions our own interpretations of these emotional states. In other words, secondary emotions are “feelings about our feelings”.
For example, my mother has always reacted to the open expression of emotion with a perplexing discomfort that had always bothered me. I desired support and understanding and instead I received stoicism. While she hadn’t intended to, as a child I perceived this as rejection….
Today with the benefit of 20/20 hindsight I have an appreciation for our differences. My mother was raised in a collectivist society in which daily life centered around the extended family. Identity, for my mother has always included an appreciation of her family role. For example, to this day everyone calls here “Nene”, which in Tagalog means baby. Additionally, I’ve come to understand her love as not a matter of words but a quiet and unspoken fulfillment of her “duty” as my mother. This concept of “duty” is strange and unfamiliar as an American. Individualism and pride are consistent with our way of doing things.
Due to these differences, my mother reacts to the open expression of emotion negatively, I become annoyed by this response, and an endless cycle of misunderstanding develops. From my mom’s perspective if emotions cause disharmony and impede the fulfillment of her duties as a mother, it is selfish and unnecessary to do so. Understanding this has been helpful in rebuilding our relationship.
Born in 1938 in the Philippines, I’m sure there is a history of familial trauma that plays a part as well. The point, however, is her intention was not to make me feel “rejected”. Instead, I see her own unique emotional resilience as a quiet offering of strength and support.
Ideal & Actual Affect
In the paper I quoted above, I reference a research article titled “Cultural Variation in Affect Valuation”, (Tsai & Fung, 2006). This article describes two interesting concepts pertaining to the issue of “feelings about feelings”. Whereas our ideal affect reflects what we want to feel, our actual affect reflects our current emotional state.(Tsai & Fung, 2006). For example, research has shown that individualistic cultural orientations are more strongly correlated with values such as elation and excitement (Tsai & Fung, 2006). In contrast, collectivist cultures tend to value a more calm, peaceful and relaxed state (Tsai & Fung, 2006). When I read the first time, I immediately thought of my own mother and our relationship problems. As fundamentally eye-opening as insight was, I ended up journaling on it later. Somehow, we never saw eye-to-eye on matters growing up. In retrospect, I am now able to understand my mother’s strange and perplexing discomfort with frank emotional expression.
Understanding a Cultural Syndrome….
Being the nerd-girl I am, after reading this insight from a paper, I decided to do some personal research of my own. I found an article that discussed cultural syndromes as shared sets of beliefs, attitudes, and norms that influence one’s behavior (Eid, Deiner, 2001). It’s worth noting that my entire internship experience has required a trip to a foreign land where unusual cultural syndromes dominate all behavioral tendencies. I come from an upper-middle educated background, my parents are happily married since ’68, and are both physicians. I know little of addiction, or the experiences of my clients at the homeless shelter I intern at. It is definitely a learning experience…..
…At any rate, expounding upon the insights of Frijda & Mesquita, B. (1994), the authors of this article on cultural syndrome describe three key differences between collectivist and individualist cultures…..
“Frijda and Mesquita distinguished among three aspects of emotion that are culturally influenced. First, they considered social consequences of emotions that regulate the expression and suppression of emotions. Second, they stressed the importance of norms for experiencing different emotions. Third, they discussed social-cohesive functions of emotions.”(Eid & Diener, 2001, p. 869).
Display Rules of Emotion…
Expounding upon the insights above, Eid & Diener, (2001) state that cultures have varied unspoken rules of emotional display. Failing to understand these “unspoken rules” can often result in the violation of a social norm and some level of social rejection. In my home, an unspoken rule of emotional display existed that involved a preference for restraint and stoicism. As doctors, my parents led with their intellect. It has always been a defense mechanism. They are uncomfortable with honest expressions of emotion.
Feeling Rules “Should-Be’s”…
Eid & Diener, (2001), also mention Feeling Rules: “social norms that prescribe how people should feel in specific situations (e.g., on a wedding day, at a funeral)” (p. 869). These sorts of cultural norms, greatly influence the appropriateness and desirability of certain emotions. For example, in the research paper I excerpted from, I recall one resource mentioning culturally relevant differences in response to the emotion of pride. While I’m unable to recall the resource at the present, results indicated Collectivist Asian societies reacted more negatively to this emotion. In contrast, Americans were comfortable, openly expressing feelings of pride…
Final Thoughts… (I promise).
In this old journal of mine is information I found from somewhere on “Emotional Coaching”. It describes how to teach children to handle their feelings effectively. My parent’s own style tended to flounder between dismissive and disapproving. I spent my 20’s learning to overcome a lasting sense of shame, and inability to trust my feelings. As a parent myself, I’ve promised to provide my kids the sort of emotional coaching I yearned for as a highly sensitive child.
This resource begins by describing three common emotional coaching styles:
THE DISMISSING STYLE: parents ignore bad emotions and have a “get over it” attitude. The child feels they are being ignored and have difficulty trusting their own feelings.
THE DISAPPROVING STYLE: Here parents don’t just ignore bad emotions, they punish children for having negative feelings. This “don’t feel that way” attitude, leaves children feeling a sense of shame: that they are somehow wrong and flawed.
LAIESS-FAIRE STYLE: Parents with an “anything goes” attitude provide no guidance whatsoever. While there is plenty of acceptance, there isn’t enough nurturing guidance children need to manage emotions more effectively….
In conclusion, with this typology in mind, what follows are steps on how to provide emotional coaching to your child…
STEP ONE: Be aware of your child’s emotions. Parents who are emotionally aware are able to raise children who are also emotionally aware. Acknowledge your child’s feelings, listen, & see things from their perspective.
STEP TWO: Using shared emotions as an opportunity to connect with your child. Experience is the best educator I believe. When emotions arise & become overwhelming, this is an ideal time to help them develop skills to manage them effectively. Don’t avoid or dismiss them, instead listen and offer guidance.
STEP THREE: Listening Empathetically. listening involves supporting the child’s lived experience as if it were true in accordance with their level of understanding. Reflecting the child’s feelings back to them, lets them know you are understanding.
STEP FOUR: Help your child name the emotions. Helping a child identify their feelings and allowing them to discuss why the feel that way is critical. This allows the child to develop emotional intelligence and adaptive coping skills.
STEP FIVE: Finding good solutions. First, when disciplining a child for bad behavior, it is important to understand the problem is the behavior and not the feeling. With firm limits in place, ask your child what they want to happen to feel better and then options are available to solve things.
Chung, R. C., & Bernak, F. (2002). The relationship of culture and empathy in cross-cultural counseling. Journal of Counseling and Development : JCD, 80(2), 154-159.
Eid, M., & Diener, E. (2001). Norms for experiencing emotions in different cultures: inter-and intranational differences. Journal of personality and social psychology, 81(5), 869.
Ekman, P., & Friesen, W. V. (1971). Constants across cultures in the face and emotion. Journal of Personality and Social Psychology, 17(2), 124-129. Retrieved from: doi:http://dx.doi.org/10.1037/h0030377
Elfenbein, H.A., & Ambady, N. (2002) On the Universality and Cultural Specificity of Emotion Recognition: A Meta-Analysis. Psychological Bulletin. 128(2). 203-235.
Ellsworth, P. C. (1994). Sense, culture, and sensibility. In S. Kitayama, & H. R. Markus (Eds.), Emotion and culture: Empirical studies of mutual influence. (pp. 23-50) American Psychological Association. Retrieved from: doi:http://dx.doi.org/10.1037/10152-001
Frijda, N. H., & Mesquita, B. (1994). The social roles and functions of emotions. In S. Kitayama, & H. R. Markus (Eds.), Emotion and culture: Empirical studies of mutual influence. (pp. 51-87) American Psychological Association. Retrieved from: doi:http://dx.doi.org/10.1037/10152-002
Harmon-Jones, E., Harmon-Jones, C., Amodio, D. M., & Gable, P. A. (2011). Attitudes toward emotions. Journal of personality and social psychology,101(6), 1332.
Leu, C.M. (2001). Emotions as Dynamic Cultural Phenomena. The Journal of Linguistic and Intercultural Education, 4. 62-75.
McKay, M.; Wood, J.C.; & Brantley, J. (20107). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. Oakland, CA : New Harbinger Publications.
Pedersen, P. B., Crethar, H. C., & Carlson, J. (2008). Inclusive cultural empathy: Making relationships central in counseling and psychotherapy (1st ed.). American Psychological Association. Retrieved from: doi:http://dx.doi.org/10.1037/11707-003
Russell, A.J. (1994). Is There Universal Recognition of Emotion from Facial Expression? A Review of the Cross Cultural Studies. Psychologial Bulletin 115(1). 101-141.
Tsai, J.L, Knutson, B., Fung, H.H., (2006). Cultural Variation in Affect Valuation. Journal of Personality and Social Psychology. 90(2). 288-307. Retrieved from: http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/131977868 0?accountid=28125
Vohs, K.D., Baumeister, R.F., & Sage Productions, (2007). Encyclopedia of Social Psychology. Thousand Oaks, Calif: Sage Productions.
It is now the end of my sixth week in this internship, and I’m ready for it to end. I’ve discovered several things about myself. FIRSTLY, I have trouble with confrontation, its just not in my nature. SECONDLY, I believe my temperament isn’t exactly suited to addiction counseling in general. THIRDLY, I can’t do 70 hours a week for much longer. My body and mind aren’t having it. FINALLY, I worry too much about others opinions.
So how is my over-tired brain processing this information?
I’ve resisted this fact for far too long. The truth honestly scares me. However, I’m finally at the point of needing to say “when”. I’ve struggled to continue with my pre-determined path: graduation in just three quarters!!! Personal insecurities fuel my endeavors to try and keep up the pace. I hope to impress my intern supervisor, but to be honest she scares the crap out of me. Despite my best efforts, I find myself running repeatedly into the same old brick wall: mind is “running on fumes”. As a result, my ability remain mindful and self-aware is limited by the effects of exhaustion…
Old anxieties pop into my brain as thoughts of an uncertain future linger in my mind. Will I find a job? Can I get another internship placement in just three weeks? If not, am I willing to “sit it out” one quarter? Should I push off graduation 12 more weeks?….and with these thoughts comes a wave of depression. Are better internship opportunities really out there? What if I can’t find a job when I’m done? This endeavor would have all been for nothing. Do I really want to be an ass-wiper my entire life?
This line of thinking is turning me into a walking shit-magnet. I can’t think beyond the anxiety & depression I’ve allowed to take over. Somethings really gotta give here.
What do I mean about this exactly?
Don’t worry, I’m not quitting altogether. I’m just accepting the fact that this pace isn’t “doable”. I need to take a break next quarter and notify my site supervisor of my plans. Once the quarter is done, a period of transition will be essential so my replacement can take over. I will then be able to start looking for a new internship placement. Currently, the effort is pointless, since nobody is really willing to consider taking on an intern “last minute”.
A strange irony exists in the contrast between my struggles & advice I provide to group therapy participants. I need to follow my own advice, & stop being a hypocrite….
As much as I love pissing-n-moaning, more can be said about my own shit-stained thinking. I’m creating the anxiety and depression through my own perspective and thought process. The problem isn’t so much a matter of what I’m looking at, as how I’m looking at it. In the remainder of this post I hope to “get real” with myself. What have I learned from my client’s this week? How might my own psychoeducational group therapy material apply to my own situation?
INSIGHT #1: “H.O.P.E = hold on pain ends”
This week while at my internship site, I visited a nearby homeless shelter. As I stood in line for my lunch, I overheard one resident comment to another that HOPE is an acronym that stands for the phrase: “hold on pain ends”. She heard it after a recent stay at an acute inpatient psychiatric unit. The backstory she provided to this creative catchphrase if hope as an acronym added another layer of depth to it. She has endured great emotional suffering and lived to tell the story. Now as she works at rebuilding her life this insight goads her forward as a light at the end of the tunnel. Hope is like light at the end of the tunnel. With intense emotional suffering, sometimes the only way out is through. No magic pill exists that makes it all better. There isn’t anything that can be said to instantaneously cure your hurt. The only realistic solution is to endure….
As Winston Churchill once said, “If you’re going through hell, keep going.”
INSIGHT #2: The 10/80/10 Rule…
Last week I met with my professor. I was in desperate need of clarity. He shared with me an interesting insight. Oftentimes when we are anxious it pertains to uncertainties in our future. A scary unknown sits before us, outside our control. It is terrifying in light of the vastness of potential outcomes…
…behind us lies the past: with memories good and bad. When reminded of traumas and losses of long ago, old hurts can re-emerge. Depression quickly follows as one’s mind is filled with memories from long ago. Very quickly, when depression takes over, it is hard to “dig your way out of it”…
With this unique persoective of anxiety and depression in mind, my professor then notes how they can take you out of the past. Anxieties, reflective of future uncertainties, cause us to live in a world of what-if’s in our future. Depression causes us to leave the world of the here and now as old hurts preoccupy our mind. We’re too busy reliving old painful memories to notice what’s happening right in front of us.
Taking things one step at a time is crucial now. Looking at what I have on my plate now and acting on my best interests is critical. I can’t take care of others if I’m unwilling to care for myself…
In a previous post I review a favorite self-help author of mine, Brene Brown (link above). I first learned about her from a now-famous Ted Talk video (see link above). Through her work, I was first introduced to the concept of shame: “an intensely painful feeling that we are flawed, and therefore unworthy of accepting and belonging” (Brown, 2006, p45). In this post, I’d like to continue with this train of thought & share some insights on how to recognize shame. While no real preventative cure to shame exists, if you are aware of what triggers feelings of shame, you’re empowered to grow beyond its confines. What follows are insights I’ve recorded in an old journal based on Brene Brown’s work on shame resilience….
FIRST: Insights on the Nature of Personal Growth.
Before I begin discussing the subject of shame, I’d like to first make some comments on the nature of personal growth overall. Despite the inherent growing pains, it is worth the effort. Having wormed her way through the rabbit hole of personal growth, there are three insights are worth noting here….
#1 – With increased self-knowledge comes an awareness of the extent of any personal ignorance.
With heightened self-awareness comes an inability to deny and ignore any issues in your life. We become aware the path that lies before us a perplexing ignorance builds in response to increased self knowledge. We now know we don’t know, (which I guess is something), however we still have a ways left to go.
Working through unresolved hurt and processing it, is critical for healing. As I’ve discovered personally, you perpetuate what you deny. What I’ve discovered personally, is that numbing and denying old hurts only causes them to live within the subconscious as annoying monkey wrenches. It is only through a close examination of these monkey wrenches that an endless cycle of bullshit can be revealed.
NOW WHAT!?!?!: Understanding the Concept…
Brene Brown (2006) defines shame as “an intensely painful feeling that we are flawed, and therefore unworthy of acceptance and belonging”, (p 45). Participants in her research utilized the following adjectives to describe this emotion: “devastating, noxious, consuming, excruciating, filleted, small, rejected, diminished” (Brown, 2006, p. 45). Human beings have a strong and instinctual need for love and belonging. We are social creatures. Shame is an emotional reflection of this instinctual drive. It forces us to accept the fact that we are byproducts of the world in which we live. We create society as it in turn creates us…
Social & psychological components
Shame is a unique sociocultural emotion. The psychological component of shame reflects an individual’s inner perception of self in relation to others (Brown, 2006). Thoughts, beliefs and emotions, play a part of shame’s psychological component. At the same time this emotion is a social construct that exists as a byproduct of interpersonal experiences and sociocultural perspectives.
A double bind situation…
In her research, Brown (2006) states that shame-inducing situations are double-bind in nature. With few if any options for resolution, participants in her research felt stuck, with nothing to do but bathe in their own misery (Brown, 2006). With this stuckness come feelings of powerlessness and isolated. The following quote from Brene’s article resonates with my own ostracism as a bullied kid:
According to Brene Brown (2008), shame is a fear of disconnection from others, or not feeling good enough. Events and circumstances that produce feelings of inadequacy or ostracism are shame-producing. Shame is a result of the internalization of message from others about what is essential for love and belonging. Here are a few blog post, that provide excellent examples of the internalization of “should-be” messages created the experience of shame.
Brene Brown asserts we are all vulnerable to shame. Messages of who we “should be”, come from everywhere and pollute our thinking. Until you’re aware of these “should be’s”, they tend to re-emerge in endless perpetuity throughout your life. Random life events can trigger old memories of shame-laden messages from one’s childhood. Over time, these should be’s become incorporated in our sense of self as measuring sticks of self-worth. Developing resiliency in shame happens when we take time to understand what triggers these feelings. What event/interaction/individual/memory caused us to feel shame? What should-be messages exist within these shame triggers? Where did this “good-enough” measuring stick originate? Who instilled this should-be idea in our minds of what we must aspire to become?
With this in mind, what follows is a list of steps to begin developing a resiliency to shame.
STEP #1 – Understanding Shame’s Physical Symptoms
As a former bullied child, shame triggers produce vivid reminders of ostracism as a kid. For me, shame triggers are those things that remind me I’ve failed in living up to a pre-defined social standard of what good-enough should equate to. Its for this reason that feelings of shame are associated with stress and anxiety. In the presence of reminders of painful experiences, our body is sent into a fight-or-flight mode. Breathing increases, your heart starts pounding, your hands shake, and you start to sweat. .
A school textbook I have defines coping styles as “persistent, consistent, collections of physiological and behavioral responses to stressful stimuli” (Lambert & Kinsley, 2011, p. 379). Additionally, research on the brain shows two types of coping responses. Reactive coping styles are associated with higher parasympathetic activity while proactive coping styles are characterized by high sympathetic activity. Finally, its interesting to note how each coping style influences our level of perceived stress. According to Lambert & Kinsley (2011), proactive coping responses show low levels of activity in a part of the brain called the HPA-Axis. In contrast, reactive coping styles show heightened levels of reactivity in the same region.
So what is an HPA Axis you ask??? Watch this video….
So why does this matter???
Basically, what this research says is that those with proactive coping styles allow some individuals to experience lower levels of stress when faced with a challenging situation (or in this case a shame trigger) (Lambert & Kinsley, 2011). In contrast those with reactive (or passive) coping styles are experience higher levels of stress and less effective coping responses to challenging situations (Lambert & Kinsley, 2011). Interestingly, this reflects research I described in a recent post on the intelligence of emotions here and here……
and for those who are disinterested in clicking the link’s above, here a cliff-notes summary of these two posts…
Emotions play a critical role in our moral judgments. These affective processes occur subconsciously, outside our awareness. They affect our information processing, thought processes, and behaviors (Cushman, et al 2010).
Two systems of moral reasoning exist in the brain. A deliberate process utilizes cost-benefit analysis to maximize one’s overall, well-being. The other is an evolutionary adaptation in the brain promoting survival. It is rapid, automatic and guided by limbic-based moral absolutes (Cushman, et al, 2010).
When faced with a situation deemed by our minds as highly stressful (i.e. shame trigger), rapid limbic responses to moral decisions are based on absolutes and reflect adeontological perspective(Cushman, et al, 2010).
In contrast, when encountering situations perceived as non-emergent and within our capability to handle effectively, a deliberate cost-benefit analysis occurs. This sort of judgment process reflects aconsequentialist perspective (Cushman, et al, 2010).
What sort picture does this research paint of how coping styles affect moral judgment?
Lambert & Kinsley (2011) indicate that proactive coping responses are associated with lower levels of activity in the HPA Axis an area of the brain responsible for the stress response. Cushman, et al, (2010) indicate that in the presence of lower stress response, the brain reacts with a more deliberate system of moral judgment that reflects a cost-benefit approach. In contrast, passive coping styles are associated with higher HPA Axis activity and a heightened stress response (Lambert & Kinsley, 2011). Cushman, et al, (2010) indicate that in the present of a perceived stressful situation, the brain reacts with a rapid-fire limbic reaction that reflects an absolutist deontological perspective.
In light of all this information, it appears understanding our shame triggers is actually quite vital?
Those things that cause shame, send us into fight-or-flight mode. Shameful experiences are perceived as a threat to our instinctual need for love, belonging, and acceptance. What causes us to feel shame? Triggers that remind us of should-be messages from other of what “good enough” is. In a never-ending desire to prove oneself “worthy of belonging”, we can fall into a perpetual fight-or-flight mode. As the above research indicates, shame triggers lead to stress, which hijacks our entire brain, hindering our ability to handle situations effectively.
STEP #2 – First an attitudinal adjustment…
Empathy – the opposite of shame…
In her research, Brene Brown (2006), notes that empathy sits at the opposite end of the continuum from shame. In her article she describes empathy “as the ability to perceive a situation from another person’s perspective – to see, hear, and feel the unique world of the other” (Brown, 2006, p. 47). She continues by noting that it comprises four key attributes:
The ability to see things as someone else does, remain judgmental, understand their feelings & communicate this effectively.
Finding sources of empathy, connection and support, are superb antidotes to shame. It is also worth noting the part of the shame equation in your control. The personal component of shame, pertains to how we incorporate others opinions into our own personal measuring stick.
Brown, (2006), also states that the degree to which we acknowledge our personal vulnerabilities influences a person’s degree of resilience to shame. In fact, whether or not we’re willing to accept this fact, nobody has the right to tell us “who we are”. We are ultimately responsible for how other people make us feel. What opinions become incorporated into our self-perception is a matter of our own determining.
STEP #3 – Shame Triggers
I’ve always had this belief that the key to empowerment is self-responsibility. Understanding our role in things is critical to identify the actionable solution. Knowing your shame triggers is so important for exactly this reason. Since shame is a feeling which is based on messages of perceived worth, understanding where these messages come from is important. Feeling the need to “measure up” is an inevitable byproduct of our own evolutionary social needs. Shame triggers are simply those events, situations, and/or relationships that lead to feelings of shame. Examining these shame-inducing situations and/or relationships requires closer examination….
What are your unwanted identities?
In her research, Brene states that shame is associated with situations that a person’s unwanted identity. Unwanted identities are simply personal characteristics that undermine who we wish to be in the eyes of others. Has there ever been a time in your life when you said “I don’t want people to thin I am a…”? Here are some of mine:
The thing to remember is we all have shame triggers. There are unwanted aspects of ourselves we hope to avoid and can’t see with any clarity. Shame-laden messages from others cloud our vision. The following questions have been helpful in allowing me to gain some perspective…
Where does this perception come from?
Why is this identity unwanted
What measuring-stick underlies it?
What if you were reduced to this unwanted identity?
STEP #3 – What are your Defense Mechanisms?
With an understanding of our shame triggers, it is next important to examine how we defend ourselves against this shitty feeling. What unconscious defense mechanisms do we do to prevent other people and/or events from causing us to feel this way? When overcome with shame, we are overcome by the effects of the brain’s HPA axis. It sets of a series of events throughout the body that create an alarm-bell stress reaction. Brene, (2010) describes two primary types of defense mechanisms that I understand as forms of conformity or rebellion. When reading her descriptions I hear both my sisters story and my own. Here are a few links to recent posts in which I reflect to my own preferred defense mechanisms:
The final piece of the puzzle is simply “getting real” with yourself. When overcome with shame you often can’t see beyond the fear of exposure that a flawed self lies inside. Attempting to see the bigger picture at such moments is important. Asking yourself a some bigger picture questions. Here are excerpts from my own journal…
As a bullied child raising a bullied child, I can think of fewer experience more shame-inducing. To see things from the other side of the coin is truly a mind-fuck. Needless to say, these things occur within a larger sociocultural context and kids tend to fall between the cracks. Teachers and principals are overworked. A child’s behaviors are often a reflection what they see going on in the home. Here is my own follow-up post to provide a bit of perspective on things.
Debunking the Ugly Duckling B.S.
While I haven’t blogged on this issue yet, I’ve always felt I have a “meat suit problem”. The issue in my case is one of having such a “wonderful personality”. These random characteristics defining my own meat suit leave me feeling “less than”. I hate my nose. I need to lose weight. At best, I’m an ignorable BLAH on a good day.
Mind you, these are just a few examples. I’ll end this post with a few final thoughts directly from an old journal…
Brown, B. (2006). Shame Resilience Theory: A grounded theory study on women and shame. Families in Society. 87(1), 43-48.
Brown, B. (2008). I Thought it was Just Me: But it Isn’t: Telling the Truth about Perfectionsim, Inadequacy, and Power. Gotham.
Brown, B. (2010). The gifts of imperfection: Let go of who you think you’re supposed to be and embrace who you are. Center City, Minnesota: Hazelden Publishing.
Brown, B. (2012). Daring greatly: How the courage to be vulnerable transforms the way we live, love, parent, and lead. London: Penguin.
Brown, B. (2015). Rising strong. Random House: New York.
Cushman, F., Young, L., & Greene, J. D. (2010). Our multi-system moral psychology: Towards a consensus view. The Oxford handbook of moral psychology, (1-20).
Lambert, K., & Kinsley, C.H. (2011). Clinical neuroscience: The neurobiological foundations of mental health. 2nd Ed., New York, NY: Worth Publishers
Miller, J.B., & Stiver, I.P. (1997). The healing connection: How wome form relationships in therapy and life. Boston: Beacon.
In this post, I’m reviewing a few old papers I’ve written on PTSD….
As this blog develops, I find it is serving two purposes. The first is as a brain dump, where I can purge all the thoughts and feelings lurking in my mind after a long way. The second function for this blog is as a study tool. As a verbal processor, my greatest successes in retaining information comes through reading it and then summarizing information in a manner that makes sense to me. That is the purpose of this post.
A Multifactorial Perspective…
Ultimately, therapists seek to make sense of human nature, one client at a time.As a PTSD sufferer, I have both a professional & personal interest on the subject of dissociative PTSD. What follows is a gathering of all research I’ve done thus far on the subject. In my studies, I am fascinated at how complex human nature truly is. As I learn more, I become increasingly aware of my expansive ignorance is: there is much to learn. The first conclusion I came to was that “making sense of human nature” requires a multidimensional perspective.
*For example, systems theory can help us understand individuals as byproducts of their family & community environment.
*Eric Berne’s work is useful in making sense of complex social transactions.
*Finally, DBT’s biosocial perspective can provide understanding of how our mental health exists as a byproduct of the interaction between one’s biology and environment.
Lambert & Kinsley, (2011) describe this multidimensional perspective by noting that biological, developmental, environmental, interpersonal, psychological and cultural perspectives are all useful in this endeavor to study human nature. From within each perspective is another unique piece of the puzzle.
Preston, et al, (2013) state that “the brain is a complex ecosystem that depends on a large number of interrelated variables” (p8). For this reason, it is important for therapist to understand the influence of neurochemical, neuroanatomical, and neurophysiological changes on behavior and mental health (Lambert & Kinsley, 2011). Therapists need an understanding of how brain anatomy correlates with various cognitive functions. A basic knowledge of brain physiology and underlying electrochemical processes are also vital. For example, when helping an individual recover from a stroke, the nature of the injury is important. Whereas, right sided strokes result in higher emotional lability, left-sided strokes are correlated with compulsive behaviors and aphasia. Another useful example of this comes from recent research on dissociative PTSD. Lanius, et al, (2010) state that dissociation is best understood as a defense mechanism to prolonged trauma. Alterations in the brain function associated with some PTSD sufferers, include an overly-inhibited limbic system, and hyper-regulation in the prefrontal cortex (Lanius, et al, 2010). These changes correlate with the dissociative symptoms often found in PTSD sufferers. Examples such as these shed light on the importance of understanding the biological underpinnings to observed symptoms. This background of knowledge is critical in the development of effective treatment plans for clients.
Lambert & Kinsley, (2011) also mentions genetics and the importance of a developmental perspective as yet another critical point of understanding human behavior. Genetics is vital in determining’s one’s overall mental health predisposition. A developmental perspective is useful in understanding the influence of one’s early childhood experiences on their mental health. In reality, these perspectives are two sides of the same coin from a nature vs. nurture standpoint. For example, my oldest son has a congenital heart defect called pulmonary atresia. As a “hidden disability”, while my son appears physically normal, he has had to adjust to an array of developmental issues. My mother is a retired Geneticist, and has provided a useful perspective on this matter. She states that her job is best understood as a “G.P. of rare and unusual conditions”. Additionally, she notes that since her diagnoses have no cure, her biggest role is helping parents work through difficult information. Her advice has been that genetics only provides part of the picture. How parents handle and adjust to this information greatly influences the developmental course of children with congenital defects. Applying my mother’s insight to personal research on this subject has provided confirmatory evidence of her advice. For example, a study by Berant, et al, (2001) looks at the influence of mothers’ attachment styles on the development of infants with heart defects. Securely attached mothers are found to develop better coping methods in response to the prolonged stress (Berant, et al, 2001) Additionally, research on the long-term effects of congenital heart defects on psychosocial development indicate family coping styles have a huge impact on a child’s well-being (Brown, et al, 2008). While this is only one example, it provides a convenient illustration of the importance of nature and nurture in one’s overall lifelong development.
Evolution & Sociocultural Perspectives
Lambert & Kinsley, (2011), also briefly mention the importance of environment, evolution, and culture as key factors in understanding our clients. Together evolution and environment are useful in contextualizing how individuals adapt to their environment. Recent research on the brain has shown a surprising degree of lifelong neuroplasticity that allows us to adjust and adapt to our surroundings. Culture provides an excellent example of how widely varied environments can be and their influence over our. For example, a book by Kathleen Taylor (2006) provides the following definition: “Brainwashing is characterized in wholly negative terms as a kind of mental rape…[the] intention is to destroy the victim’s faith in former beliefs to wipe the slate clean so that new beliefs can be adopted” (p4). This westernized perspective on brainwashing, is likely to be met with a divergent interpretation from collectivist societies. As Kathleen Taylor (2006) states individuals from China, tend to view this experience as “morally uplifting and harmonizing” (p5). While reading this, I was reminded of a recent conversation with my mother, who is from the Philippines. As a culture with a more collectivist background, she has stated that American individualism, can often appear as prideful and selfish to foreigners. This convenient example, is also effective in illustrating the influence of culture. Culture is more than a set of beliefs and values. It defines our way of being in the world, by predefining our way of understanding it. In this respect, culture determines our emotional and cognitive responses to life events.
Preston, et al, (2013) state that “a single model for understanding and treating mental disorders is too narrow and simply inadequate” (p13).
In fact, in an attempt to better understand human nature, it is clear that the whole is not equal to the sum of its parts. We influence our world and are influenced by it in turn. An understanding of human nature from a biomedical, sociocultural and developmental perspective are all critical. For example, a biomedical perspective is important in observing a client’s response to medications. In contrast, sociocultural competency and developmental psychology are important in understanding the effects of one’s environment and life experiences. In light of all this, a lifelong commitment to personal development is critical, since it appears we give to others on the basis of who we are.
Having described my approach to therapy, I’d like to discuss what I’ve learned do far about PTSD…
What is Dissociative PTSD?
In the new DSM-5 manual, PTSD is no longer classified as an anxiety disorder. Instead it is classified under a new category titled “Trauma and Stressor-Related Disorders”, (American Psychiatric Association, 2013). Gateway criterion for this disorder define trauma as an “exposure to actual or threatened death, serious injury or sexual violence” (American Psychiatric Association, 2013, p. 271). Additionally, while PTSD’s traumatic stressors can include either direct or indirect, the requirement of “fear, helplessness and horror” (Friedman, 2013, p. 550) is no longer required. Other symptoms include (1) a persistent avoidance of triggers, (2) alterations in mood and cognition, (3) flashbacks; and (4) alterations in arousal and reactivity (American Psychiatric Association, 2013). Finally, two new subcategories of PTSD are included in the new DSM-5 Manual, including a developmentally relevant subcategory for children, and dissociative subtype.
Symptoms & Life Situation.
What is it like to experience symptoms of dissociative PTSD and what are their consequences for one’s daily life? Dissociation causes a fragmentation of one’s awareness and an inability to utilize cognitive processes to perceive the “real self” in relation to the environment (Armour, et al, 2014, Lanius, et al, 2012). Dissociation includes symptoms of depersonalization and derealization. Depersonalization is a feeling of detachment that is often described as an outer body experience. In contrast, derealization results in the feeling that one’s world is unreal and dreamlike (American Psychiatric Association, 2013). While PTSD is associated with emotional under-modulation and symptoms of hyper-arousal, the dissociative subtype is associated with persistent emotional over-regulation (Lanius, 2010). A study by Griffin, et al, (1997), is helpful in understanding the consequences of this unique feature of dissociative PTSD. In this study, 85 rape victims were interviewed and asked to discuss details surrounding the traumatic event (Griffin, et al, 1997). Measures of heart rate and skin conductance were taken during the interview (Griffin, et al 1997). Upon completion of the interview, participants filled out the PTSD symptom scale. A subset of individuals was shown to have high levels of incongruence between their own report of distress in comparison to physiological measures (Griffin, et al, 1997). Research like this supports the conclusion that dissociation is a defense mechanism of prolonged trauma, especially of a sexual nature (Armour, et al, 2014; Griffin, et al 1997; Lanius, et al 2012). The following lasting consequences exist as a result of this maladaptive defense mechanism:
*Unmanageable disconnection: Individuals with Dissociative PTSD describe an unmanageable disconnection well after trauma exposure. While this dissociation is a useful defense mechanism during trauma, it prevents individuals from fully engaging in life. For this reason, sufferers often experience anhedonia, diminished interests, and a higher rate of depression and anxiety (Lanius, 2012).
*Difficulty processing Trauma: Persistent avoidance and dissociation interfere with the habituation process that occurs during exposure therapy (Wabnitz, et al, 2013). Until sufferers can begin woking through these experiences, they will have little insight how these past traumas have affected them. Additionally, since dissociative PTSD is associated with prolonged trauma, the effects of underlying symptoms are profound. This disorder is associate with high rates of divorce and job insecurity (Armour, et al, 2014; Griffin, et al 1997).
*Insecure Attachment & Perceived Hostility: dissociative PTSD is associated with “exaggerated negative beliefs [and] expectations…of others” (American Psychiatric Association, 2013, p. 272). Armour, et al, (2014), describes a hostile attitude, defined by distrust and an over-arching perception of ill intent, in sufferers of this disorder. Additionally, sufferers of this disorder frequently exhibit dysfunctional attachment styles. As a result, sufferers of dissociative PTSD have an array of belief systems that act as self-fulfilling prophecies in all relationships. Until these issues can be worked through, they will continue to influence all present and future relationships in a “like-attracts-like” fashion.
*Anxiety & Persistent Avoidance: Exposure to reminders of past trauma produce feelings of anxiety and hyper-arousal. In order to prevent re-experiencing old traumas, sufferers will engage in a hyper-vigilant avoidance of anything that triggers these memories. When this is not possible, dissociative symptomatology arrises as described earlier.
Controversies & Validity…
Support for Dissociative PTSD…
Research providing rationale for inclusion of Dissociative PTSD indicates that this disorder has a unique clinical presentation and responds differently to treatment. Dissociative PTSD is associated with ‘”chronic child abuse, sexual abuse, and prolonged trauma” (Wabnitz, et al, 2013). Early studies on prevalence rates indicate that 70% of PTSD sufferers fall into the re-experiencing category and 30% qualify for the dissociative subtype (Lanius, et al, 2012). Additionally, while the re-experiencing group shows lower activity in the prefrontal cortex and hyperactivity in the limbic system, the opposite can be said of the dissociative subtype (Lanius, et al, 2012). Finally, in support of the validity of dissociative PTSD, research shows a differential response pattern to conventional exposure therapy (Lanius, et al, 2012).
A Continuum of Dissociation.
Prior to inclusion in the DSM-5 manual, dissociation has been considered to be a predictor of the development of PTSD (Wabnitz, et al, 2013). Smptoms of dissociation found in the DSM-5 disorders can be arranged from simple to complex (Wabnitz, et al, 2013). While the dissociation found within acute stress disorder has a simple presentation, it is much more complex within dissociative identity disorder. In contrast, Dissociative PTSD, can be found at a midpoint between these extremes. Currently, no research exists which has studied the varied presentation of dissociation within these diagnoses. For this reason, critics question whether Dissociative PTSD is indeed a unique subtype or if it is a component of one’s adaptive responses to a trauma (Armour, et al, 2014; Wabnitz, et al, 2013).
Component vs. Subtype Models.
A wealth of research exists to support the connection between PTSD and experiences of dissociation (Armour, et al, 2014). However, there is disagreement on the specific relationship between trauma and dissociation. Armour, et al, (2014), describe two causal models with different proposed relationships between dissociation and trauma. While both models conclude that dissociation is a defense mechanism to trauma, they disagree on whether research supports inclusion in the DSM-5 Manual (Armour, et al, 2014). Supporters of the component model point at the varied presentation of dissociation across diagnoses and state they are simply co-occurring factors (Armour, et al, 2014; Wabnitz, et al, 2013). In contrast, the subtype model points at the fact that heightened levels of persistent dissociation change the nature of PTSD symptoms (Armour, et al, 2014). In an effort to encourage research to clarify the matter, dissociative PTSD has been included in the new DSM-5 Manual (Friedman, 2013).
As stated earlier, PTSD is no longer classified as an anxiety disorder. This change reflects research that shows PTSD is not best understood as a fear-related issue (Friedman, 2013). Instead, the updated version of PTSD provides a diagnosis for the DSM-5 manual based on a cause (Levin, et al, 2014). Changes to gateway criterion of PTSD no longer require a specific emotional response such as fear or horror (Friedman, 2013). Instead, the definition of trauma has been expanded to aid diagnoses. Based on these observations, Levin, et al, (2014) suggest a structured interview of an individual’s trauma history, is now vital for accurate diagnosis. the clinician administered PTSD scale for DSM-5 (CAPS-5) is an example of a tool that can aid in this assessment (Bauer, et al, 2013). Developed by the U.S. Department of Veteran’s Affairs, This tool is designed for use as a semi-structured interview (Bauer, et al, 2013). In addition to clustering scores in accordance with DSM-5 criteria, it assesses the impact of symptoms on an individual’s overall functioning (Bauer, et al, 2013). In this respect, subsequent administrations of this tool, are useful in assessing a client’s response to treatment.
Consequences of a Broad Definition.
While a narrow definition of PTSD simplifies diagnosis, a broad construct was designed to provide the most accurate clinical picture of PTSD (Friedman, 2013). Levin, et al, (2014), note that this broad definition makes diagnosis much more complex. Some symptom categories are difficult to assess objectively and require client self-report (Levin, et al, 2014). This adds an extra layer of complexity to the diagnosis of dissociative PTSD (Levin, et al, 2014). For example, criterion D refers to persistent belief of oneself in relation to others. Dissociative PTSD is associated with a prolonged history of trauma, insecure attachment and a hostile perception of others (Armour, et al, 2014). With low levels of insight into these issues, assessing Criterion D symptoms in dissociative PTSD sufferers is problematic. An accurate diagnosis of dissociative PTSD must account for its unique clinical presentation including the consequences of persistent emotional over-regulation.
As stated earlier, dissociation is a symptom that can be found in varying degrees throughout the DSM-5 (Wabnitz, et al, 2013). To avoid any confusion, it is important to note that not every exposure to trauam or extreme distress causes PTSD. While a careful assessment of gateway criterion for this disorder is important, alone it is not enough. In order to differentiate PTSD from other trauma-related diagnoses, a traumatic event should precede other PTSD symptoms (American Psychiatric Association, 2013).
Another source of diagnostic confusion, is the need to differentiate personality disorders from criterion D of PTSD which describes a “persistent and exaggerated negative belief about oneself [and] others” (American Psychiatric Association, 2013, p. 272). Personality disorders present interpersonal disturbances that reflect pervasive and lifelong patterns of beliefs, behaviors and inner experience (American Psychiatric Association, 2013). It is also worth noting that personality is defined as a pattern of thoughts and behaviors, unique to an individual that define how they relate to others. The interpersonal issues experienced by PTSD sufferers can be understood as a byproduct of unresolved traumatic events. They are coping responses and not evidence of one’s character.
A final source of confusion worth mentioning, is the difference between dissociative PTSD and DID, (dissociative identity disorder). Dissociative symptoms in DID, involve a pervasive amnesia related to everyday events followed by flashbacks and a loss of time. Additionally, DID includes a disruption of identity states that cause the compete loss of a personal sense of agency that is unrealted to trauma (APA, 2013). In contrast Dissociative PTSD is associated with transitiry experiences of amnesia, falashback, depersonalization, adn derealization (American Psychiatric Association, 2013).
Final Comments on Diagnosis…
Diagnosis of dissociative PTSD must include an assessment of the severity of dissociative symptoms alongside relevant v-codes. These diagnostic considerations are critical for treatment planning. For example, individuals with low levels of dissociation can show successful outcomes with cognitive therapy alone (Lanius, et al, 2012). In contrast, higher levels of dissociation require a stage-oriented approach that provides a form of DBT skills training, in emotional regulation, distress tolerance, and mindfulness for grounding purposes, prior to EMDR or exposure therapy (Lanius, et al, 2010; Lanius, et al, 2012). Finally, it is also worth noting that sufferes with dissociative PTSD have complicated abuse and trauma histories. This has a profound affect on one’s attachment style and interpersonal relationship habits. Assessing this issue thoroughly and addressing it in family therapy may also be warranted (Armour, et al, 2014).
Treatment & Medication
In an article by Jepsen, et al, (2013), research was conducteed on the effect of dissociation and interpersonal dysfunction on the treatment of chronically sexually abused adults. A group of 48 individuals were followed on a year-long treatment process. results of this study indicate that pathological dissociation and interpersonal difficulties significantly affected treatment outcomes (Jepsen, et al, 2013). Since dissociation is best understood as a defense mechanism to prolonged trauma it isn’t surprising. Additionally, evidence such as this, indicates a careful assessment of dissociation is essential for effective treatment in cases of complex trauma.
Dissociation affects an individual’s arousal response to triggers. In dissociative PTSD, the prefrontal cortex over-regulates the limbic system (Lanius, et al, 2010). As a result the system is overly-inhibited and dissociative symptomatology is a result. Dissociative symptoms, impede the effectiveness of interventions aimed at effective trauma processing. The habitual learning processes associated with classical conditioning in these trauman processing techniques are also interfered with through dissociative symtomatolgoy. Exposure therapy alone, is not effective for this reason.
Neurobiology of PTSD
“The human stress response is…a complex biological system…built around the capacity for rapid recognition of potentially harmful stimuli to mobilize the specific-specific defense response.” (Friedman, 2015, p9). In PTSD, this stress response is sustained longer, becoming maladaptive. A basic knowledge of the maladaptive neurobiology underlying PTSD is critical to understanding how medications can be utilized to treat and prevent this disorder. What follows is a listing if biochemical alterations in the nervous system of individuals with PTSD:
Thalamus: PTSD is associated with an impaired relay of information from the thalamus to cortex during arousal, causing symptoms of both dissociation and hyper-arousal.
Amygdala: Receiving information from the thalamus, the amygdala provides information regarding any potential threat (Weiss, 2007). The emotional valance of a potential threat is a byproduct of messages sent from the amygdala to the HPA axis as well as the skeletal muscles (Friedman, 2015).
Hypothalamic-Pituitary-Adrenal (HPA) Axis: The HPA axis, comprises the flight-or-flight response of the neuroendocrine system (Lambert & Kinsley 2011). It is responsible for producing many of the physical symptoms associated with prolonged stress. Evidence of HPA axis dysregulation in PTSD is most readily evident in elevated levels of corticotrophin releasing hormone (CRH) and glucocorticoids (Friedman, 2015).
Prefrontal Cortex (PFC): The PFC is responsible for making cognitive decisions about emotional responses, and acts as a regulator in this respect (Weiss, 2007). In PTSD, alterations in emotional regulation can be seen as correlating with maladaptive responses. Dissociation correlates with an overregulation of the limbic area by the PFC (Friedman, 2015). In contrast, hyperarousal is the result of under-regulation by the PFC of the limbic system (Friedman, 2015).
Hippocampus: The hippocampus is responsible for establishing conscious experiences into memories. Trauma victims have been found to have smaller hippocampal regions (Weiss, 2007). It is felt this is related to symptoms of avoidance, dissociation, and numbing (Friedman, 2015).
Neurochemical Alterations: Elevated levels of cortisol and epinephrine are related to flashbacks, hyper-arousal, and panic attacks (Weiss, 2007). Norepinephrine, effective in maintaining alertness, and focus, is associated with PFC impairment, and ineffective amygdala restraint (Friedman, 2015). Chronic serotonin activation, common in PTSD, is associated with symptoms of hyper-vigilance, irritability, and re-experiencing (Weiss, 2007). In contrast, altered Dopamine levels in PTSD are associated with dissociative symptoms as well as hyper-vigilance (Friedman, 2015).
History of Medications Utilized to Treat PTSD
Changes in the classification of PTSD and addition of new subtypes, indicate that the presenting symptoms for this disorder are likely to vary. Consequently, these “different phenotypes of PTSD…might be best addressed by different therapies” (Friedman, 2015). Research is currently ongoing that can provide a better understanding of the symptomatic variations for the PTSD subtypes. Hopefully, in time, this can lead to medications that are specifically designed to address these varied PTSD subtypes more effectively. In the meantime, what follows of a review of treatments utilized currently in the treatment of PTSD symptoms.
Anxiolytics for PTSD
In the 1980’s, when PTSD first appeared in the third edition of the DSM, Benzodiazepines were the preferred medication to treat this disorder (Bernardy, Souter & Friedman, 2015). These anxiolytics are effective in enhancing the inhibitory amino acid GABA by binding with benzodiazepine receptors, and enabling calcium channels to open more fully (Lambert & Kinsley, 2011). Initially thought to be effective in reducing symptoms of hyper-arousal, clinical practice guidelines no longer support the use of benzodiazepines for PTSD (Bernardy, Souter & Friedman, 2015). Side effects of benzodiazepines can include, drowsiness, stomach upset, cognitive impairment, memory loss, nightmares, and changes in heart rate (Preston, et al, 2013). Examples of benzodiazepines include Diazepam, Temazepam, and Lorazepam (Preston, et al, 2013). With a lack of support regarding their effectiveness in alleviating PTSD symptoms, benzodiazepines are associated with withdrawal, tolerance and dependence. Most notably, Research in support of this clinical standard notes that “benzodiazepines may interfere with the extinction of fear condition…[and] worsen recovery” (Bernardy, Souter, &, Friedman 2015, p78).
Antidepressants for PTSD
Since the 1990’s great progress has been made in how to effectively treat PTSD, due to an understanding that symptoms overlap depression and anxiety (Bernardy & Friedman, 2015). Based on this insight, recent research has focused on the effectiveness of Selective Serotonin Reuptake Inhibitors (SSRI) for PTSD. SSRI’s, currently a first line treatment for PTSD, enhance the effectiveness of Serotonin by increasing the availability of this neurotransmitter. It addresses symptoms of irritability, depression, anxiety, avoidance, and numbing (Bernardy & Friedman, 2015). Examples of SSRI’s include Celexa, Paxil, and Zoloft. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s), are another first line treatment of PTSD, found equally effective in clinical trials, improve resilience in handling stress (Bernardy & Friedman, 2015). These medications increase the availability of norepinephrine and serotonin and include drugs such as Cymbalta and Effexor (Preston, et al, 2013). Occasionally, Tricyclics and Monamine Oxidase Inhibitors (MAOI’s) are utilized to treat PTSD, although they are not considered a first line treatment for this disorder due to a long-list of side effects (Bernardy & Friedman, 2015).
Atypical Antipsychotics & Anticonvulsants
Recent research has shown mixed results regarding the effectiveness of SSRI’s in the treatment of PTSD (Bernardy & Friedman, 2015). Additionally, there are currently “limited medication options available for the treatment of PTSD” (Jeffreys, 2015, p89). For this reason, research is now focusing on broadening the list of secondary options for PTSD. Atypical antipsychotics and anticonvulsants have been studied as potential treatments for complex presentations of PTSD that include comorbid diagnosis and a history of substance use (Jeffreys, 2015). While atypical antipsychotics target serotonin, anticonvulsants inhibit GABA in the central nervous system. Their effectiveness in research is mixed-at best, and only suggested in complex cases of PTSD as described above (Jeffreys, 2015). They are to be utilized with caution due to a wide array of associated side effects.
Medication Utilized to Prevent PTSD
A new wave of research has been underway that addresses the question of whether or not it is possible to prevent PTSD with early pharmaceutical interventions (Lambert & Kinsley, 2011). The theoretical perspective underlying this innovative approach states that PTSD occurs in those cases in which the fear response to a traumatic event doesn’t extinguish fully and instead becomes habituated (Kearns, et al, 2012). Exposure therapy is effective in extinguishing a condition fear response associated with PTSD since it involves the activation of fear memories, and the incorporation of corrective information (Kearns, et al, 2012). Preventative treatments for PTSD are based on the notion that inhibiting the process of memory consolidation during a traumatic event can halt the development of this disorder.
Overview of Medication. One class of medications thought to be effective in the prevention of PTSD are beta-blockers such as Propranolol (Carter & Hall, 2007). Beta Blockers are medications useful in the treatment of high blood pressure, chest pain, and anxiety. As anxiolytics, they are useful in treating “peripheral manifestations of anxiety (increased heart rate, sweating, tremor), but are not very effective at blocking the internal experience of anxiety” (Preston, et al, 2013, p217). Side effects include anxiety, irritability, hyperventilation, sleep difficulties, shakiness, restlessness, GI upset, and dry mouth (Preston, et. al, 2013).
Therapeutic Effects. The therapeutic effects of Beta Blockers in the prevention of PTSD are based on the notion that regulating catecholamine dysfunction can prevent PTSD symptoms. Research supporting this has indicated PTSD sufferers have decreased cortisol levels and elevated CRF, indicating an inability to regulate catecholamines (Searcy, et al, 2012). For example, one study compares the effects of Metopropolol, a noradrenergic antagonist with Yohimbine, a noradrenergic agonist on the recall of emotionally arousing events. Results showed that Yohimbine provided increased memory recall of emotionally arousing material, indicating that noradrenergic medications can modulate memory formation (Searcy, et al, 2012).
Research Evidence. In one study, participants were administered Propranolol within 2-20 hours after a motor vehicle collision (Searcy, et al, 2012). A follow-up of participants in this study showed that only one individual who received propranolol reported symptoms of PTSD (Search, et al, 2012). Another study, reporting similar effectiveness of Propranolol as a preventative, theorizes that this effect is due to a limited epinephrine-enhanced fear conditioning (Kearns, et al, 2012). However, despite this promising evidence, a thorough review of clinical evidence, shows mixed results in support of Propranolol (Searcy, et al, 2012).
Overview of Medication. Another medication that may be effective in preventing PTSD, is the corticosteroid hydrocortisone. “Hydrocortisone is used to treat adrenal failure, shock, and inflammatory, allergic, and rheumatic conditions” (Hydrocortisone, 2014). All studies utilizing hydrocortisone as a preventative medication for PTSD in this paper were administered I.V. The side effects of glucocorticoid treatment are too numerous to list and involve the GI system, cardiovascular system, immune system, central nervous system, and endocrine system (Schäcke, et al, 2002).
Therapeutic Effects. Glucocorticoids, such as hydrocortisone, play an essential role in modulating the behavioral and physiological responses to stress in order to maintain homeostasis (Zohar, et al, 2011). Normally, in the aftermath of trauma, individuals work through a process of reconsolidation, in order to make sense of what has transpired, and develop an acceptable narrative of recent events (Glazer, 2011). Individuals at risk for PTSD, struggle in the aftermath of a trauma, to make sense of what has happened. Neurobiological evidence of this difficulty can be seen in evidence of lower levels of cortisol after trauma, causing impairments in memory formation (Glazer, 2011). Hydrocortisone is thought to impact a person’s ability to reconsolidate memories through is effects on the hippocampus (Zohar, et la, 2011).
Research Evidence. Early studies on hydrocortisone as a PTSD preventative utilized rats and showed this medication modulated the fear response (Searcy, et al, 2012). Two subsequent studies involving human subjects involved the administration of IV Hydrocortisone to acutely ill ICU patients (Searcy, et al, 2012). In both studies, this medication was very effective in reducing the incidence of PTSD symptoms of its subjects (Searcy, et al, 2012). In contrast, studies utilizing long-term sufferers of combat trauma, indicate a temporally based window of opportunity (Kearns, et al, 2012). Studies such as these, which utilize long-term PTSD survivors, show a temporary reduction in symptoms that return over time (Kearns, et al, 2012). To understand the neurobiological correlates of these therapeutic effects other research examines the neuroanatomy of animals with steroid-treated stress (Zohar, et al, 2011). “Steroid-treated stressed animals displayed significantly increased dendritic growth and spine density with increased levels of brain-derived neurotropic factor” (Zohar, et al, 2011, p796).
An Ethical Controversy
While there is scant evidence that other medications may prove effective in preventing PTSD, the Hydrocortisone and Propranolol, hold the greatest promise. The effectiveness of these drugs in preventing PTSD, are all based on their ability to affect on the establishment of long-term memory. It is for this reason, that the utilization of these drugs is somewhat controversial. Carter & Hall, (2007), address this controversy by asserting that ethical objections of memory dampening medications such as propranolol, should be weighted against long-term negative consequences of PTSD.
Therapy for Dissociative PTSD???
In this final section, I set aside the research and speak from personal experience. Therapy for my own process of recovery occured over the span of almost a decade. It began when I entered individual therapy, and met an insightful therapist who encouraged me to enter a DBT skills group. On completion, I began working toward utilizing these skills throughout my personal life. Over the years, I came to understand how my entire existence became polluted by this issue. I worked on my relationship with my kids, and how I parented them. I addressed unhealed wounds within my family in the aftermath of the shared trauma of those “it years”. Finally, once my therapist and I were certain my coping skills were strong enough, we did a some EMDR, for purposes of trauma processing. The path was a long one, and took time, but well worth the effort…
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